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American Eagle Flight 3008 ALPA Submission

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American Eagle Flight 3008 ALPA Submission SUBMISSION OF THE AIR LINE PILOTS ASSOCIATION TO THE NATIONAL TRANSPORTATION SAFETY BOARD REGARDING AN INCIDENT INVOLVING AMERICAN EAGLE AIRLINES FLIGHT 3008 Santa Maria, CA January 2, 2006 1 SUMMARY..........................................................................................................................................3 2 HISTORY OF FLIGHT......................................................................................................................3 3 WEATHER ..........................................................................................................................................5 3.1 WEATHER RADAR ........................................................................................................................ 5 3.2 AIRMETS ................................................................................................................................... 5 3.3 CONCLUSION................................................................................................................................5 4 OPERATIONS.....................................................................................................................................5 4.1 DEFERRED DE-ICE TIMER CONTROL SYSTEM .............................................................................. 5 4.2 STALL WARNING SYSTEM............................................................................................................ 6 4.3 STALL RECOVERY TRAINING ....................................................................................................... 6 4.4 AUTOPILOT USAGE ....................................................................................................................... 6 5 FINDINGS............................................................................................................................................7 6 RECOMMENDATIONS.....................................................................................................................8 2 1 Summary On January 2, 2006 a Saab 340 aircraft operated by American Eagle Airlines as flight 3008 encountered icing conditions during an enroute climb over Santa Maria, California. At 11,700 feet mean sea level, (msl) the airplane departed controlled flight and descended to 6,500 feet msl before the crew was able to regain full control. The crew having declared an emergency elected to continue to their scheduled destination at Los Angeles International Airport (LAX) where they landed without further incident. The airplane did not sustain any damage and there were no injuries reported by the 2 flight crew members, 1 flight attendant, or 25 passengers onboard. The flight had originated from San Luis County Regional Airport (SBP), San Luis Obispo, California. As party to this investigation, The Air Line Pilots Association, International (ALPA) is providing this submission to present our analysis of the factual records and provide recommendations to reduce the risk for future incidents or accidents that could occur under similar circumstances. 2 History of flight The incident flight was the fifth trip of the day for the flight crew, and their second trip in the incident airplane. On the trip prior to the incident flight, the captain was the pilot flying and had observed light rime ice accumulating on the wing surface and windshield wipers during their descent from 9,000 to 5,000 feet msl into SBP. The de-ice boot system was operated manually because the de-ice timer control system was logged as inoperative from a previous flight. The crew had an uneventful landing at SBP and arrived at the gate about 15 minutes late with an anticipated turnaround time of 20 minutes. While at the gate the captain took time to review the dispatch weather information which included two AIRMET (airmen’s meteorological information) reports that indicated a possibility of icing in clouds. Based upon the information he had, the captain concluded that the anticipated weather conditions fell within operational criteria defined by the American Eagle S340 Airplane Operating Manual (AOM) as “Ice Protection Level 2”. The airplane was equipped with the icing protection systems required by the AOM for these conditions which included Left & Right Engine anti-ice operational and the Wing/Stab boots operational either in the continuous mode or activated manually. Because the de-ice timer control system was reported to be inoperative the crew anticipated having to activate the Wing/Stab boots manually if needed. And as an extra precaution due to the short runway and gusty wind conditions anticipated at takeoff, it was decided that the captain would fly the initial departure and then transfer control authority to the first officer (FO) at the airplane’s acceleration altitude. The flight departed from SBP in instrument meteorological conditions (IMC) with the captain flying the takeoff and initial climb as planned. At 2,500 feet msl the FO assumed the pilot-flying duties with the autopilot engaged in the medium (M) Climb mode which according to the AOM provides pitch commands to maintain approximately 160 knots indicated airspeed (KIAS), depending on the aircraft’s pressure altitude. Shortly after taking control the FO then selected the Vertical Speed (VS) mode of the autopilot which maintains the rate of climb present at the time of VS mode selection. While in the VS 3 mode the autopilot will allow the airspeed to vary in order to hold constant the selected rate of climb. According to the Digital Flight Data Recorder (DFDR) at the time the autopilot transitioned to VS mode the airspeed briefly decreased from 160 to about 135 KIAS then accelerated up to 180 KIAS as the airplane continued in the climb. According to the AOM, “VS mode may be used for enroute climbs, but the crew shall pay particular attention to IAS (indicated airspeed).” The AOM further states, “If climbing during ice accretion or with residual ice on the airframe, IAS is the only FD/AP mode authorized. However, other vertical modes may be used temporarily to transition to an appropriate climb speed.” The captain, according to his statements, diligently looked for possible ice accumulation on the wings, propellers and windshield wipers through out the climb because they had encountered icing conditions on their inbound trip. Up to this point when the crew initially transitioned the autopilot from Climb to VS they had not yet encountered ice accretion and was operating in accordance with their AOM procedures. Their AOM minimum climb speed was 126 KIAS for a clean wing and 141 KIAS if in icing conditions (Vcln+15). The flight was cleared to continue directly to the San Marcus VOR and the crew intended to climb to an altitude of about 13,000 feet msl. The autopilot remained selected in VS mode and according to the DFDR, at 9,200 feet msl the airspeed which had been holding steady at 180 KIAS during the climb began a gradual decrease along with a simultaneous increase in pitch angle. According to the NTSB Performance study the airplane’s aerodynamic lift and drag characteristics exhibited during the deceleration were consistent with the accumulation of ice forming on the airframe. At 11,000 feet msl when according to the DFDR the airspeed had decayed to 140 KIAS, the captain first noticed light rime ice on the windshield wipers and then on the leading edge span of the left wing. At about 11,500 feet msl, with the airspeed continuing to decay the captain began to initiate the manual de-ice boot sequence which requires a crew member to depress the de-ice controls in a certain order, as described in the AOM. This manual operation requires the focused attention of a flight crew member and therefore degrades overall attention for monitoring the status of other items such as airspeed. Within seconds after the captain had directed his attention to the manual de-icing sequence, the cockpit windows became opaque due to a layer of ice. The captain reported that while he was reaching up to engage the de-ice system, the clacker and stick-shaker activated, indicating an imminent stall. According to the DFDR the airspeed had decayed to 118 KIAS as the airplane entered into an aerodynamic stall at about 11,700 feet msl. Moments later the autopilot, which was still selected in the VS mode, disengaged. The captain, who had been focused on the manual de-icing sequence, immediately declared that he was taking control of the aircraft. The airplane began a rapid decent with the wings oscillating. After several oscillations the captain was able to control the decent and stabilize the airplane as it passed through 6,500 feet msl. According to his statement, an immediate concern was to exit IMC and get the airplane below the freezing level. The captain maintained a rate of decent of 500 feet per minute (fpm), declared an emergency to the air traffic controller, and requested a block altitude. He flew the airplane in a controlled descent to about 5,000 feet msl heading in a westerly direction toward the ocean and over Santa Maria, California. During the decent he said that he could hear “large ice masses” impact the sides of the fuselage. The captain opted to continue the flight to LAX, 4 recognizing that the runways were longer and more emergency facilities were available than the surrounding airports. He made several cabin calls to inform the passengers of the situation and explain that he was now in control of the airplane. The airplane was landed at LAX without further incident. 3 Weather 3.1 Weather Radar According to the weather
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